CAMPFIRE BOYS & GIRLS 1-2002 - Laserfiche WebLink

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,",'r''" """, ...., Disclosure of Lobbying Activities Approvad by OMS 0348-0046 Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352 (See reverse side for Instructions and Public Reporting burden statement) 1. Type of Federal Action 2. Status of Federal Action 3. Report Type o a. contract D a. bid/offer/application D a. initial filing b. grant b. initial award b. material change c. cooperative agreement c. post-award For Material Change Only d. loan year (yyyy) ______ quarter ______ a. loan guarantee f. loan insurance date of last report (mm/dd/yyyy)_____ 4. Name and Address'of Reporting Entity 5. If Reporting Entity in No.4 is Subawardee, enter Name and Address DPrime DSubawardee Tier __' if known: of Prime Congressional District, if known Congressional District, if known 6. Federal Department/Agency 7. Federal Program Name/Descrlption .. CFDA Number, if applicable ________ 8. Federal Action Number, if known 9. Award Amount, if known $ 10a. Name and Address of Lobbying Registrant b. Individuals Performing Services (including address if different from NO.1 Oa.) (if individual, last name, first name, MI) (last name, first name, MI) 11. Amount of Payment (check all that apply) (attach continuation sheet(s) if necessary) 13. Type of Payment (check all that apply) 12. Form of Payment (check all that apply) D a. retainer D b. one~time fee D c. commission o d. contingent fee D e. deferred D f. other (specify)_______________________ 14. Brief Description of Services Performed or to be Performed and Date(s) of Service, including officer(s), employee(s), or Member(s) contacted, for Payment Indicated in Item 11 Da Db cash $ actual planned in-kind; specify: nature value (attach continuation sheet(s) if necessary) 15. Continuation sheets attached DYes D No 16. Information requested through this form is authorized by Sec.319, Pub. L. 101-121. 103 Stat. 750, as amended by sec. 10; Pub. L. 104- 65, Stat. 700 (31 U.S.C. 1352). This disclosure of iobbying activities is a material representation of fact upon which reliance was placed by the above when this transaction was made or entered into. This disclosure is required pursuant to 31 U.S.C. 1352. This information wiil be reported to the Congress semiannuaily and will be available for public inspection. Any person who fails to file the required disclosure shail be subject to a civil penalty of not less than $10.000 and not more than $100,000 for each such failure. Federal Use Only: Signature D-\ c::u........ ). ~lO\l~ e-xecvK""'f ~r TalephoneNo. (!'It.;) !?'i~C;:'\.<\\ )(1(. Print Name Title Date (mmfdd/yyyy) Authorized for Local Reproduction Standard Form.LLL (7/97)